Nonoperative Versus Operative Treatment for Displaced Finger Metacarpal Shaft Fractures: A Prospective, Noninferiority, Randomized Controlled Trial.

UPDATE: This article was updated on January 18, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 103, in the first column of Table III, the continuous outcomes, which had been given as "Median" and "(range)", are now given as "Mean" and "(95% CI)", respectively.

Finger metacarpal fractures represent up to 31% of all hand fractures, and most can be treated nonoperatively. Whether operative treatment is superior to nonoperative treatment for oblique and/or spiral finger metacarpal shaft fractures (MSFs) is unknown. Forty-two patients with displaced oblique and/or spiral finger MSFs were randomized to either nonoperative treatment with unrestricted mobilization or operative treatment with screw fixation. The primary outcome was grip strength in the injured hand compared with the uninjured hand at the 1-year follow-up. Secondary outcomes were the Disabilities of the Arm, Shoulder and Hand score, range of motion, metacarpal shortening, complications, sick leave duration, patient satisfaction, and costs. All patients attended the 1-year follow-up. Mean grip strength relative to that in the contralateral hand was 104% (95% confidence interval [CI], 89% to 120%) in the nonoperative group and 96% (95% CI, 89% to 103%) in the operative group (p = 0.34). Mean metacarpal shortening was 5.3 mm (95% CI, 4.2 to 6.4 mm) in the nonoperative group and 2.3 mm (95% CI, 0.8 to 3.9 mm) in the operative group. In the nonoperative group, 1 minor complication was observed; in the operative group, there were 4 minor complications and 3 reoperations. The costs were estimated at 1,347 U.S. dollars (USD) for nonoperative treatment compared with 3,834 USD for operative treatment. Sick leave duration was significantly shorter in the nonoperative group (12 days [95% CI, 5 to 21 days] versus 35 days [95% CI, 20 to 54 days]) (p = 0.008). When treated with unrestricted mobilization, patients with a single displaced spiral and/or oblique finger MSF have outcomes comparable to those treated operatively, despite metacarpal shortening. Costs are substantially higher (2.8 times) and sick leave is significantly higher in the operative group. Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Reconstruction of the distal radioulnar joint with rib perichondrium - midterm follow-up.

BACKGROUND: Reconstruction of an osteoarthritic distal radioulnar joint (DRUJ) in patients with high physical demands and a long lifetime expectancy is challenging. A variety of methods like implant surgery and salvage procedures as partial or total ulnar head resection and the Sauve-Kapandji procedure are reasonable options in the elderly patient but not in young individuals since it often compromises manual power and stability and may cause impingement problems. Reconstruction of the DRUJ with rib perichondrium is a new treatment option with promising short-term outcome. The aim the present study was to investigate if the outcome is consistent over time. METHODS: Four female patients with a mean age of 40.5 years suffered severe unilateral osteoarthritis in the DRUJ. They underwent reconstruction of the joint with rib perichondrium transplants. Preoperatively, mean pain under manual load was 8.5 (range 7-10) and 4.2 (range 2-5) at rest, using the visual analogue scale (VAS). Range of motion (ROM) in forearm rotation was on average 118° and grip strength was 86% in comparison to the contralateral hand. The outcome was assessed at a clinical follow-up in 2016, measuring ROM, grip-strength, pain at rest and under manual load and DASH-score. Radiological examination was performed. An additional follow-up by letter was performed in 2021 using a patient-reported-outcome survey (PROS). The patients were asked to grade the ROM and grip-strength as changed or unchanged in comparison to the clinical follow-up in 2016. RESULTS: At clinical follow-up at a mean of 3.1 years (range 1-5) after surgery, pain level had decreased to VAS 1.5 (0-5) under load and all patients were pain free at rest. Forearm rotation was on average 156° (range 100-180) and grip strength was 97% of the unoperated hand. The mean DASH-score was 14.4 (0-45). An additional follow-up by letter was conducted at a mean of 7.5 years (5.5-9.5) after surgery. ROM and grip strength were reported as unchanged by all patients in relation to the previous clinical follow-up. No additional surgery or complications were reported. CONCLUSION: Reconstruction of the osteoarthritic DRU-joint with rib perichondrium transplantation can provide good clinical outcome with perseverance over time. LEVEL OF EVIDENCE: IV.

Optimized protocols for in situ hybridization, immunohistochemistry, and immunofluorescence on skeletal tissue.

Assessment of gene and protein expression in tissue sections is instrumental in medical research. However, this is often challenging to perform on skeletal tissues that require prolonged decalcification and have poor adhesion to slides. In this study, we optimized selected steps of in situ hybridization (ISH), immunohistochemistry (IHC), and immunofluorescence (IF) for formalin fixed and decalcified skeletal tissues. Sections from distal femur of 6-, 8- and 14- week-old rats injected with BrdU with or without a hemizygous eGFP transgene expressed under the control of a ubiquitous promotor were used. We report that proteinase K digestion is critical for the sensitivity of ISH, as concentrations that were too strong and too mild both resulted in loss of signal. In addition, intensified RNase A digestion removed nonspecific riboprobe-mRNA hybrids. Furthermore, enzymatic antigen retrieval using proteinase K provided more consistent results in IHC and can therefore be a useful alternative to heat induced epitope retrieval (HIER) for skeletal tissues where such treatment often damages the morphology. A mild proteinase K digestion also improved IF detection of GFP and worked well for double labeling IF of GFP and osteocalcin on frozen sections of formalin fixed and decalcified rat bones while maintaining morphology. In summary, this study provides strategies to improve protocols for enzymatic digestion in ISH, IHC, and IF for skeletal tissues and also demonstrates the importance of careful optimization and validation with the use of these techniques.

Rat perichondrium transplanted to articular cartilage defects forms articular-like, hyaline cartilage.

OBJECTIVE: Perichondrium autotransplants have been used to reconstruct articular surfaces destroyed by infection or trauma. However, the role of the transplanted perichondrium in the healing of resurfaced joints has not been investigated. DESIGN: Perichondrial and periosteal tissues were harvested from rats hemizygous for a ubiquitously expressed enhanced green fluorescent protein (EGFP) transgene and transplanted into full-thickness articular cartilage defects at the trochlear groove of distal femur in wild-type littermates. As an additional control, cartilage defects were left without a transplant (no transplant control). Distal femurs were collected 3, 14, 56, 112 days after surgery. RESULTS: Tracing of transplanted cells showed that both perichondrium and periosteum transplant-derived cells made up the large majority of the cells in the regenerated joint surfaces. Perichondrium transplants contained SOX9 positive cells and with time differentiated into a hyaline cartilage that expanded and filled out the defects with Col2a1-positive and Col1a1-negative chondrocytes and a matrix rich in proteoglycans. At later timepoints the cartilaginous perichondrium transplants were actively remodeled into bone at the transplant-bone interface and at post-surgery day 112 EGFP-positive perichondrium cells at the articular surface were positive for Prg4. Periosteum transplants initially lacked SOX9 expression and despite a transient increase in SOX9 expression and chondrogenic differentiation, remained Col1a1 positive, and were continuously thinning as periosteum-derived cells were incorporated into the subchondral compartment. CONCLUSIONS: Perichondrium and periosteum transplanted to articular cartilage defects did not just stimulate regeneration but were themselves transformed into cartilaginous articular surfaces. Perichondrium transplants developed into an articular-like, hyaline cartilage, whereas periosteum transplants appeared to produce a less resilient fibro-cartilage.

Interosseous-lumbrical adhesions - a rare condition? A series of five cases.

Adhesions between the interosseous and lumbrical muscles involving the deep transverse metacarpal ligament (dTML) can be a cause of chronic pain and reduced range of motion. New reports on this condition are rare. We identified five patients experiencing pain, swelling and decreased range of motion in the metacarpophalangeal (MCP) joints during manual load. The condition was caused by a direct trauma. After not responding to conservative treatment, patients underwent surgery. Time between trauma and surgery was on average 16 months and the mean postoperative follow-up was 8 months. The lumbrical-interosseus junction was exposed by volar or dorsal incision, adhesions were widely released and the distal third of the dTML was resected. This resulted in normal passive excursion of the muscles and the tendon junction. At the mean follow-up time 8.2 months (3-18) after surgery, all patients were pain-free and had gained near normal range of motion in the MCP joints. Interosseous-lumbrical adhesions may be more common than reflected by the literature. Hand surgeons should keep this condition in mind in cases with chronic inter-metacarpal pain after trauma or infection. Surgical exploration is relatively straight forward and tends to lead to gratifying results. Level of Evidence: IV (therapeutic).

Two-component surface replacement implants compared with perichondrium transplantation for restoration of Metacarpophalangeal and proximal Interphalangeal joints: a retrospective cohort study with a mean follow-up time of 6 respectively 26 years.

BACKGROUND: The aim of our study was to compare the long-term outcome after perichondrium transplantation and two-component surface replacement (SR) implants to the metacarpophalangeal (MCP) and the proximal interphalangeal (PIP) joints. METHODS: We evaluated 163 joints in 124 patients, divided into 138 SR implants in 102 patients and 25 perichondrium transplantations in 22 patients. Our primary outcome was any revision surgery of the index joint. RESULTS: The median follow-up time was 6 years (0-21) for the SR implants and 26 years (1-37) for the perichondrium transplants. Median age at index surgery was 64 years (24-82) for SR implants and 45 years (18-61) for perichondium transplants. MCP joint survival was slightly better in the perichondrium group (86.7%; 95% confidence interval [CI]: 69.4-100.0) than in the SR implant group (75%; CI 53.8-96.1), but not statistically significantly so (p = 0.4). PIP joint survival was also slightly better in the perichondrium group (80%; CI 55-100) than in the SR implant group (74.7%; CI 66.6-82.7), but below the threshold of statistical significance (p = 0.8). CONCLUSION: In conclusion, resurfacing of finger joints using transplanted perichondrium is a technique worth considering since the method has low revision rates in the medium term and compares favorable to SR implants. LEVEL OF EVIDENCE: III (Therapeutic).

Reconstruction of finger joints using autologous rib perichondrium - an observational study at a single Centre with a median follow-up of 37 years.

BACKGROUND: Gratifying long-term results are difficult to achieve when reconstructing osteoarthritic finger joints. Implant surgery is the most commonly used method to restore function and dexterity. However, all types of implant have disadvantages and may be a less favorable option in some cases, especially in young patients with a long expected lifetime and high demands on manual load. Implant related complications as loosening, instability, subsidence and stiffness are the main concerns. In this context, joint reconstruction using rib perichondrium might be a reasonable alternative in selected cases. The aim of the study was to evaluate the long-term results of finger joint reconstruction using rib perichondrial transplantation. METHODS: The study group (n = 11) consisted of eight individuals reconstructed in the proximal interphalangeal (PIP) joints and three reconstructed in the metacarpophalangeal (MCP) joints during 1974-1981. All patients were evaluated at clinical visits (median: 37 years after perichondrial transplantation, range: 34-41 years) using radiographs, disability in arm-shoulder-hand (DASH) score, Visual Analog Scale (VAS), range-of-motion (ROM) and manual strength (JAMAR). RESULTS: None of the 11 patients had undergone additional surgery. All of the PIP-joints (n = 8) were almost pain-free at activity (VAS 0,6) (range 0-4), had an average range-of-motion of 41 degrees (range 5-80) and a mean DASH-score of 8,3 (range 1-51). The mean strength was 41 kg compared to 44 kg in the contralateral hand (93%). The three MCP joints were almost pain-free at activity (VAS 0,7), (range 0-1). The ROM was on average 80 degrees (range 70-90) and the mean DASH-score was 2 (range 1-3). The mean strength was 43 kg compared to 53 kg in the contralateral hand (81%). CONCLUSIONS: Perichondrium transplants restored injured PIP and MCP joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure. Additional studies are needed to evaluate long-term results in comparison to modern implants and to better describe the factors that determine the outcome of these procedures. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Interosseous-lumbrical adhesions secondary to an infection: a case report.

INTRODUCTION: Adhesions between the tendons to the interosseous muscles, the lumbrical muscles and occasionally the deep transverse metacarpal ligament can be symptomatic and cause chronic discomfort in the distal part of the hand. Reports about the condition are rare and the causal factors in previous publications are in principle limited to crush injuries and contusion from a direct blow to the hand. We present a case with typical clinic findings secondary to an infection after a cat bite. To the best of our knowledge symptomatic interosseous-lumbrical adhesions caused by an infection has never been described previously. CASE PRESENTATION: Our case report describes a 25-year-old Caucasian woman with chronic pain and swelling between her second and third metacarpal heads. Symptoms occurred especially under stress and developed secondary to an infection after a cat bite. Surgical exploration revealed localized adhesions between her second lumbrical muscle, her first palmar interosseous muscle and her deep transverse metacarpal ligament. The symptoms were completely relieved by surgical release of the adhesions, partial resection of the deep transverse metacarpal ligament and immediate postoperative physiotherapy. CONCLUSIONS: Physicians involved in hand surgery should be aware of the condition and look for it in patients complaining about distal intermetacarpal pain. The major causal factors for developing symptomatic interosseous-lumbrical adhesions are crush injuries or contusion to the distal part of the hand but it may also occur after an infection.

Resurfacing the distal radioulnar joint with rib perichondrium-a novel method.

Background Osteoarthritis in the distal radioulnar joint (DRUJ) is a challenging condition with few really reliable surgical options, particularly in young individuals. Traditional methods as hemiresection, the Darrach procedure, and the Sauvé-Kapandji procedure have less favorable results in the nonrheumatoid patient. The results after implant arthroplasty have improved, but long-term results are yet to be presented before implant arthroplasty can be recommended to young individuals with osteoarthritis in the DRUJ. An alternative method to treat osteoarthritic joints is surface replacement with free costal perichondrium. The technique has been used since the 1970s for other joints. Case Description We adapted the method and used it in two female patients (37 and 38 years old) with nontraumatic osteoarthritis in the DRUJ. Both patients had severe pain and were unable to work. The eroded joint surfaces were resected down to bleeding subchondral cortex. Perichondrium from the seventh rib was osteo-sutured and glued to the ulnar head and the sigmoid notch. Results The maximum follow-up-time in this retrospective review is 25 months. Our short-term results are encouraging in terms of pain relief, motion, grip strength, and return to work. The first patient had an excellent result and was completely normalized. The second patient has improved significantly and experiences only slight pain on heavy lifting and rotational load. Clinical Relevance Free costal perichondrium may be a useful alternative for treating osteoarthritis in the DRUJ, especially in young individuals. The option for a later implant arthroplasty is preserved because most of the anatomy of the joint and all the soft tissue stabilizers are intact. Level of Evidence Therapeutic IV, Case series.

Ectopic bone formation after medial femoral condyle graft to scaphoid nonunion.

Free vascularized bone graft from the medial femoral condyle has been described as a superior method for treatment of recalcitrant scaphoid nonunion with proximal pole avascularity and humpback deformity. Few complications and high union rates have been reported. In a series of three patients we describe an undesired volar ossification as a potential complication of the method. The risk of developing the ectopic bone formation can be minimized if the surgeon is aware of the strong osteogenic capacity of the periosteum. Meticulous dissection of the vascular bundle to the graft is mandatory to avoid the complication. Caution is warranted so as not to leave a periosteal sleeve under the vessels at the margin of the graft.

Parsonage-Turner syndrome and a localised swelling around the extensor tendons of the hand: a clinical sign indicating increased risk of rupture of the tendon.

Two patients presented with intense pain in the shoulder followed by weakness and paralysis of muscles in the shoulder and arm, together with a peculiar swelling on the hand. The swelling seems to predispose to rupture of the extensor tendon. If this tumour is a regular finding in Parsonage-Turner syndrome, it may also help in making a definitive diagnosis.

Blood flow to the extensor carpi radialis brevis muscle following adrenaline infusion in patients with lateral epicondylitis.

PURPOSE: Based on previous evidence of muscle fiber injury and decreased blood flow in the extensor carpi radialis brevis (ECRB) muscle in lateral epicondylitis (LE), we hypothesized that there would also be an abnormal (vasoconstrictive) vascular response to adrenaline in the ECRB muscle in LE. METHODS: In a case-control study, we measured skeletal muscle blood flow in 8 patients with LE and in 8 healthy controls in response to a 30-minute intravenous infusion of adrenaline. We used local clearance of technetium-99m in the main portion of the ECRB muscle to calculate muscle blood flow. RESULTS: In support of the hypothesis, the blood flow response to the adrenaline infusion was markedly different in the 2 study groups. Whereas the continuous decrease in technetium-99m clearance rate over time was interrupted by the adrenaline-induced vasodilatory effect in the control group, we detected no such effect in the patient group. CONCLUSIONS: In the ECRB muscle in LE, there is a shift in the balance of vasodilatory and vasoconstrictory influences of adrenaline, leading to vasoconstriction during low-dose adrenaline infusion. The adverse adrenaline effect is similar to what was previously observed after minor muscle injury. Whether the vasoregulatory change, by causing relative muscle ischemia, represents the primary etiology in LE or results from muscle injury cannot be determined, but it is likely to contribute to the development and continuation of chronic muscle pain in LE. New ways of thinking about the condition may be required, and pharmacological treatment might be an option to improve the blood supply and avoid further damage to the affected ECRB muscle-tendon unit.

Intravenous adrenaline infusion causes vasoconstriction close to an intramuscular microdialysis catheter in humans.

AIM: To test if a small muscle injury influences the vascular reactivity to adrenaline in human skeletal muscle. METHODS: Blood flow was measured by ¹³³Xenon clearance in the gastrocnemius muscle of eight male subjects at basal and during i.v. infusion of adrenaline (0.1 nmol kg⁻¹ min⁻¹) or placebo. Measurements were done with (expts 2 and 3) or without (expt 1) the influence of a small muscle injury induced by inserting a microdialysis catheter. ¹³³Xenon was administered either (expt 1) conventionally into the muscle via a fine needle, or (expts 2 and 3) through a fine tube close to the inserted microdialysis catheter. Expt 3 (control expt) was identical to expt 2 except that placebo was infused instead of adrenaline. Mean ± SEM, n= 8. RESULTS: The blood flow tended to increase during the adrenaline infusion in expt 1 (1.17 ± 0.10 to 1.39 ± 0.15, N.S.), whereas it decreased during the adrenaline infusion in expt 2, from 1.39 ± 0.14 to 1.03 ± 0.14 ml min⁻¹ 100 g tissue⁻¹ (P<0.001). The blood flow change in response to adrenaline infusion was significantly different in expt 1 and expt 2 (P<0.05). Blood flow also decreased during the placebo infusion in expt 3 (1.15 ± 0.10 to 1.00 ± 0.09, P<0.01), but this decrease was significantly smaller than in response to the adrenaline infusion in expt 2, P<0.01. CONCLUSION: The present results are consistent with the hypothesis that the small muscle injury caused by the inserted microdialysis catheter influences the vascular reactivity to adrenaline in a vasoconstrictive direction.

Alterations in forearm position and environmental temperature influences the segmental volume expansion during venous occlusion plethysmography--special attention on hand circulation.

AIM: To find evidence that small changes in the positioning of the strain gauge, the environmental temperature (sympathetic activation) and position of the arm (venous pressure) alters the outcome of the venous occlusion plethysmography (VOP) measurement of forearm blood flow and to investigate if the hand circulation influences the results. METHODS: Forearm blood flow was measured with VOP (n = 6) on three occasions with air temperatures of 13, 20 and 38 degrees C, respectively. At each occasion the arm position was varied; raised by 10 degrees , horizontal or lowered by 15 degrees . Strain gauges were placed on the forearm at the maximal circumference; 5 cm distal; and 5 cm proximal to this site, respectively. The hand circulation was excluded in half of the measurements. RESULTS: The simple main effect of temperature was highly significant (P<0.001). With excluded hand circulation (but not when included), there was a two factor interaction between arm position - strain gauge position (P<0.05). The highest expansion rate was found in the proximal segment when the arm was elevated, but in the distal segment when the arm was lowered. With hand circulation (but not without) there was a two factor interaction between temperature and strain gauge position (P<0.01). The highest expansion rate was found in the distal segment at normal and high temperatures, but in the proximal segment at low temperature. CONCLUSION: The volume expansion rate in a particular segment is dependent not only on arterial inflow. Segmental differences in capacity for venous expansion results in redistribution of blood to and from a segment, thus influencing the results obtained.

Influence of leg position and environmental temperature on segmental volume expansion during venous occlusion plethysmography.

Blood flow determinations by venous occlusion plethysmography applying the strain-gauge technique are frequently used. A problem with the strain-gauge technique is that the relationship between venous volume and transmural pressure is not linear and, furthermore, changes with the sympathetic tone. The present study tests the hypothesis that these factors lead to a redistribution of venous blood, which may impair the accuracy of the technique. The relative volume expansion rates of four leg segments were studied with the leg in different positions and at disparate temperatures, thereby inducing varying venous pressures and sympathetic tone ( n =6). With elevated leg and relaxed veins (at 50 degrees C), the distal thigh showed a relatively low expansion rate (25.8+/-4.5 ml.min(-1).l(-1)), whereas values in the calf segments were higher (34.5-39.0 ml.min(-1).l(-1)). With lower initial transmural pressure, calf segments can increase their volume much more during occlusion compared with the distal thigh. In a higher transmural pressure region (lowered leg), the difference in compliance between limb segments is less. In this case, compliance and volume expansion rate was higher in the distal thigh (14.2, 13.5 and 22.2 ml.min(-1).l(-1) at 10, 20 and 50 degrees C respectively) than in the calf segments (for the distal calf: 6.4, 7.7 and 16.2 ml.min(-1).l(-1) respectively). There was a significant interaction ( P <0.001) between temperature and leg position, indicating a higher degree of sympathetic vasoactivity in the calf. It is concluded that blood flow determination by strain-gauge plethysmography is less accurate, due to a potential redistribution of the venous blood. Therefore possible influences of variations in sympathetic tone and venous pressure must be considered even in intra-individual comparisons, especially in interventional studies.